The autopsy was made by Dr. W. P. Northrup, curator of the asylum, who found the pharynx covered by a membrane which was traced to the posterior nares; larynx, trachea, and bronchial tubes as far as the third divisions also covered with membrane; portions of the tracheal surface denuded, and the mucous membrane underneath of a bright red color and smooth; tonsils sloughy and fetid; mucous membrane of smaller bronchial tubes very red and covered with viscid mucus and pus; a portion of the left lung, extending from the root posteriorly to the surface, gangrenous, discolored, and honeycombed; two or three intensely hyperæmic spots, as large as a bean, in left lung; right lung congested, but not consolidated; slight catarrh of stomach; circumscribed areas of congestion in intestines; solitary glands of intestines swollen, and some of them ulcerated; spleen of normal size, rather pale; liver congested and somewhat enlarged.
Case 3.—Katie, aged six and a third years, was returned to the asylum on Nov. 18th. Three days later (Nov. 21st) she had sore throat, reddened fauces, coated tongue, and a faint rash upon the neck, chest, and arms; eyes injected; temperature 102°. In the afternoon temperature 103°; eruption still faint. Nov. 22d, temperature 103.5°; an eruption on chest, abdomen, arms, and legs in patches. Evening, temperature 104°; voice clear. Nov. 23d, temperature 103.5°; tongue red; fauces deeply reddened, but without any visible pseudo-membrane; eruption of a scarlatinous appearance over the back and abdomen; on the extremities dusky, livid patches. P.M., temperature 104°; is slightly delirious; eruption abundant. Nov. 24th, temperature 103.5°; eruption well out on abdomen; it is the same as yesterday upon the extremities, except perhaps a little more dusky; still no pseudo-membrane to be seen upon the fauces; is restless and delirious. P.M., during the day has been very restless, suffering from dyspnoea; no croupy voice nor croupy cough, though the dyspnoea continues, and a pseudo-membrane is now visible over the tonsils and adjacent faucial surface; eruption dusky; skin cool; pulse very frequent and feeble. From this time she sank steadily, and died at 11.30 P.M. During her sickness her urine seemed to be diminished, but it was not properly examined.
Autopsy Nov. 25th by Dr. W. P. Northrup, curator: Points of redness, apparently a hemorrhagic eruption, over the face, shoulders, and parts of the trunk; a few of the same on the extremities; no pseudo-membrane visible in nostrils or in buccal cavity; brain not examined. Naso-pharynx covered by a thick fibro-purulent membrane. Larynx contains a well-marked pseudo-membrane, but not continuous. Trachea covered by a pseudo-membrane, continuous over most of its surface, but in places broken and flaky. Where it is detached the mucous membrane is seen underneath, dusky and deeply injected. At the root of the lungs the pseudo-membrane can be traced along the tubes about an inch in all directions. Lungs oedematous, with deep congestion in places, but apparently no pneumonia; about two drachms of clear, straw-colored fluid in pericardium; a few stringy decolorized clots in the cavities of the heart; left ventricle contracted. The heart-fibres, carefully examined, microscopically, in the laboratory, are found to be normal, not having undergone granular or fatty degeneration. Liver normal in size; pale-yellow areas upon the superior surface, either from anæmia or fatty deposition. Kidneys of usual size, capsule not adherent; pyramids congested; cortex pale; markings distinct. Spleen enlarged about one-third; consistence normal. Stomach and intestines not examined.
Case 4.—Scarlet fever complicated by diphtheria, nephritis, and broncho-pneumonia. (History by house physician, Dr. Swift.) Phoebe, aged three and a quarter years, was delicate, but in her usual health till Oct. 29, 1882, when she became languid and vomited several times, and her tongue was coated. Oct. 30th, occasional vomiting; fauces reddened; tongue coated. Oct. 31st, remains languid; fauces deeply reddened; a faint scarlatinous eruption over back, wrists, and feet; temperature 100.5°. P.M., eruption of scarlet fever well out over the surface; tongue cleaner. Nov. 1st, rash over entire body; temperature 100.2°. Nov. 2d, fauces deep-red; tonsils and uvula swollen; diarrhoea and vomiting. Nov. 3d, temperature 102.5°; the eruption, which has been bright red, is now more dusky. Nov. 5th, temperature 104.5°; dusky-red color of the eruption; skin beginning to desquamate in places; urine normal; a discharge from nostrils. Nov. 6th, temperature 103.5°; eruption still present, but skin of abdomen and back desquamating; has otorrhoea on both sides; fauces deeply hyperæmic, but no pseudo-membrane visible upon them. Nov. 7th, temperature 103°; respiration and cough have a slight croupy character; other symptoms as yesterday. Nov. 8th, temperature 101°. A careful inspection of the fauces shows that it contains no pseudo-membrane; nostrils discharging a dark-brownish liquid; examination of urine negative. Nov. 11th, eruption, which appears to have been hemorrhagic in points, is fading and the desquamation is less. Nov. 14th, nostrils still discharging; glands of neck swollen. Nov. 16th, temperature 103°; sp. gr. of urine 1010, no casts, nor albumen; the chest seems clear; less discharge from nostrils; fauces clean and but slightly inflamed. Nov. 17th, 18th, temperature 103.5°; vomits; lungs healthy, but breathes with considerable effort, though without stridor; urine diminished; its sp. gr. 1020, albuminous, contains blood-corpuscles and granular casts. Nov. 19th, is very pallid; temperature 104°; very restless; vomits; urine diminished; bowels freely open. Nov. 20th, respiration still embarrassed; subcrepitant râles over the entire chest and percussion resonance not clear; temperature 102.5°. Nov. 21st, physical signs the same; temperature 103.5°; respiration 80. Nov. 22d, urgent dyspnoea; dulness on percussion over top of right lung and over lower part of left lung; is delirious; no perspiration; urine scanty; bowels freely open. From this date the dyspnoea became more urgent, and death occurred at 4 P.M. on the 23d.
Autopsy by Dr. W. P. Northrup, curator: Body well nourished; slight oedema of both legs; swelling at angles of jaws, most marked on left side. Vessels of brain moderately injected; otherwise appearance normal. Cicatrizing ulcers on both sides of fauces; a diphtheritic pseudo-membrane on septum of nose, larynx normal. Trachea, upper half apparently normal; a thin film of pseudo-membrane extends from just above the bifurcation upward to nearly the middle of trachea. About an ounce of fluid in each pleural cavity; on the right side a few loose flakes of fibrin floating in the serum, and consolidation of lung at apex; collapse in one or two places. Left side, recent adhesions over whole of posterior surface and base; surface of lower lobe dark, and when it is detached strings of fibrin adhere to it, and it is consolidated. The cut surface shows marked oedema, injection, increase of mucus in bronchi, and disseminated miliary tubercles in every part; no tubercles in the pleura, and none elsewhere in the body except in the left lung; tubercles in the lower lobe larger and more thickly grouped than in the upper lobe. Decolorized clots in heart, extending from ventricles into auricles of both sides. The capacity of the ventricles seems normal. Liver and spleen, normal. Kidneys rather large; capsules not adherent; superficial veins injected. The cut surface shows congested pyramids and pale cortex; markings indistinct and irregular; about four ounces of clear straw-colored fluid in abdominal cavity, and the solitary follicles of large intestines show pigmentation; two simple intussusceptions, each three-fourths inch in length, in small intestines.
Coryza frequently commences at or about the time of the pharyngitis. The inflammation of the Schneiderian membrane is continuous posteriorly with that of the fauces, and is announced by redness and swelling, inability to breathe freely through the nostrils, and an irritating ichorous discharge. Simple coryza in itself involves little danger, though it is an unpleasant complication, and in the nursing infant it may interfere with sucking. Diphtheritic coryza, on the other hand, which is frequently present when diphtheria complicates scarlet fever, involves danger, since it is apt to cause ulcerations, hemorrhages, and septic poisoning. When the local symptoms are unusually severe and the discharge abundant, it is probable that inflammation has in some cases extended to the antrum of Highmore.
Inflammation of the middle ear is another unpleasant and not infrequent complication. It is attributed to extension of the catarrh from the pharynx along the Eustachian tube to the tympanum. In a considerable proportion of cases of otitis media this tube is occluded by the infiltration and swelling of its mucous membrane, so that the muco-pus escapes with difficulty or is retained. Hence severe earache, an increase of the febrile movement, and outward bulging of the membrana tympani occur. Sometimes headache or other cerebral symptoms arise, probably from the fact that the meningeal artery, which supplies the meninges, is connected by anastomosing branches with the tympanum. In one of the cases related above it will be recollected that the ulceration and abscess extended from the fauces to the middle ear, the entire Eustachian tube having disappeared in the ulcerative process.
Frequently, the otitis escapes detection, its symptoms being masked or obscured by the general disease, until the membrana tympani is perforated and otorrhoea begins; but by careful examination the nature of the complication can usually be ascertained before the ear is injured to this extent, for a patient too young to speak will often press with the fingers against the painful ear or lie with the ear pressed upon the pillow, evidently having an increase of suffering if placed in any other position. One old enough to speak and in proper mental condition makes known the earache as soon as it occurs.
The mucous membrane of the tympanum, red and swollen from inflammation, secretes muco-pus abundantly; and this, pent up in the cavity, must obtain an exit before relief occurs. It is well if this secretion escape, though with difficulty, down the Eustachian tube. The destructive action of the pus upon the delicate structure of the ear is often such that, within a few days, irreparable harm is done and more or less deafness results. Relief can occur, if the Eustachian tube remain closed, only by perforation of the membrane and the discharge of the secretions into the external meatus. When this occurs the inflammation in the most favorable cases gradually abates, the aperture in the drum closes, and the integrity of the auditory apparatus is preserved. In severe cases the mastoid cells participating in the inflammation become filled with muco-pus and tender to the touch, and often the collateral oedema causes tumefaction and narrowing of the external ear, which subside with the discharge of pus from the tympanum.
Unfortunately, there is for many a more melancholy history—a more destructive inflammation, involving permanent impairment or total loss of hearing. This is especially apt to occur in strumous and feeble children. All grades of inflammation and destructive action occur in different cases. The perforation in the drum-membrane may be large or the membrane may be completely destroyed, and the detached ossicles escape one by one into the external meatus, and in a few instances, fortunately rare, this occurs in both ears, producing complete and permanent deafness. In my own practice this has never occurred, but I have met one or two adults who were totally deaf from this cause.